Antithrombotic therapy before, during and after transcatheter aortic valve replacement (TAVR)

The Risk for Excessive Anticoagulation With Activated Clotting Time-Guided Monitoring in Patients Undergoing Transcatheter Aortic Valve Replacement

•An activated clotting time <250 ​seconds after an initial unfractionated heparin dose often coincided with sufficient antifactor Xa activity >0.50 U/mL, which may result in additional unfractionated heparin administration, with an increased bleeding risk.•The point-of-care-activated partial thromboplastin time may be a safer and more reliable anticoagulation monitoring tool during transcatheter aortic valve replacement procedures.

Bayesian Meta-analysis of Direct Oral Anticoagulation Versus Vitamin K Antagonists With or Without Concomitant Antiplatelet After Transcatheter Aortic Valve Implantation in Patients With Anticoagulation Indication

Patients undergoing transcatheter aortic valve implantation (TAVI) commonly have co-morbidities requiring anticoagulation. However, the optimal post-procedural anticoagulation regimen is not well-established. This meta-analysis investigates safety and efficacy outcomes of direct oral anticoagulants (DOACs) and Vitamin K Antagonist (VKA), with or without concomitant antiplatelet therapy. We searched EMBASE and MEDLINE for appropriate studies. Subgroup analyses were performed for anticoagulant monotherapy and combined therapy with antiplatelet agents. Eleven studies (6359 patients) were included. Overall, there were no differences between DOACs and VKA for all-cause mortality (Odds Ratio [OR]: .69; Credible Interval [CrI]: .40–1.06), cardiovascular-related mortality (OR: .76; Crl: .13–3.47), bleeding (OR: .95; CrI: .75–1.17), stroke (OR: 1.04; CrI: .65–1.63), myocardial infarction (OR: 1.51; CrI: .55–3.84), and valve thrombosis (OR: .29; CrI: .01–3.54). For DOACs vs VKA monotherapy subgroup, there were no differences in outcomes. For the combined therapy subgroup, there was decreased odds of all-cause mortality in the DOACs group compared with the VKA group (OR: .13; CrI: .02–.65), but no differences for bleeding and stroke. DOACs and VKA have similar safety and efficacy profiles for post-TAVI patients with anticoagulation indication. However, if concomitant antiplatelet therapy is required, DOACs were more favorable than VKA for all-cause mortality.

Effects of single versus dual antiplatelet therapy on the adverse events after transcatheter aortic valve implantation: A meta-analysis

Dual antiplatelet therapy (DAPT) was currently recommended for transcatheter aortic valve implantation (TAVI) postoperative management in clinical application. However, POPular-TAVI trial showed DAPT increased the incidence of adverse events compared to single antiplatelet therapy (SAPT). Herein, we performed a meta-analysis to investigate the effect of SAPT versus DAPT on the adverse events after TAVI. Eleven studies were available from PubMed, Embase, Cochrane Library, and Web of Science from inception to April 1, 2021. The pooled effect size was presented as relative risk (RR) with 95% confidence intervals (CIs). The sensitivity analysis was used to assess the stability of analysis results, and Begg's test was applied to evaluate the publication bias. The Cochran Q test and the I² statistic were used to evaluate the heterogeneity, and the source of heterogeneity was explored by meta-regression. A total of 4804 patients were obtained, with 2257 in SAPT group and 2547 in DAPT group. Compared to the DAPT, SAPT was associated with the decreased risk of all-cause bleeding (RR: 0.51, 95% CI: 0.44-0.61), major bleeding (RR: 0.53, 95% CI: 0.32-0.86), and minor bleeding (RR: 0.58, 95% CI: 0.34-0.98). There were no significant differences in mortality and myocardial infarction events, stroke events, and acute kidney injury between the two groups. SAPT was superior to DAPT in decreasing all-cause bleeding, major bleeding, and minor bleeding, suggesting that SAPT could be preferentially recommended for TAVI postoperative management in most patients without another indication for DAPT and oral anticoagulation.